Common Reasons for Denial

• Claim is missing a Certification of Medical Necessity or DME Information Form (Required for dates of service prior to January 1, 2023 only)
• CMN is in denied status
• Claim is missing the KX modifier
• This is not a service covered by Medicare
• Documentation requested was not received or was not received timely
• Item billed may require a specific diagnosis or modifier code based on related LCD
• Item being billed does not meet medical necessity
• Claim billed as upgrade and ABN was obtained. Beneficiary is liable

Next Step

• If CMN is in denied status, work with Supplier Contact Center to determine what was wrong with CMN, once that is determined, appeal claim
• If the remittance advice reason includes MA130, correct claim and rebill
• A Redetermination request may be submitted with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal
• Request a self service reopening if a clerical error occurred. (Missing or incorrect Diagnosis code and some modifiers)
• Collect amount from beneficiary if not paid previously for upgrade, beneficiary liable

How to Avoid Future Denials

• Review beneficiary's records to determine if a diagnosis that qualifies is indicated.
• Review related LCD for modifier criteria and verify the required modifiers are appended to the HCPC codes submitted. This can be accomplished by utilizing the Modifier Lookup Tool on the Noridian Medicare website.
• Respond to development letters with supporting documentation within designated timeline as defined on letter
• Ensure all questions on Certificate of Medical Necessity (CMN) are qualifying according to policy and submitted with claim when applicable. (Required for dates of service prior to January 1, 2023 only)